Cultural safety within an Indigenous context means that the educator/practitioner/professional, whether Indigenous or not, can communicate completely with a patient in that patient’s social, political, linguistic, economic, and spiritual realm … Cultural safety requires that health care providers be respectful of nationality, culture, age, sex, political and religious beliefs, and sexual orientation… Cultural safety involves recognizing the health care provider as bringing his or her own culture and attitudes the relationship.
National Aboriginal Health Organization, 2008, as cited in van Gaalen et. al, 2009, p. 11.
With respect to First Nation seniors, the Alianait
Inuit-specific Mental Wellness Task Group (2007) suggests that one strategy for developing a culturally safe and culturally competent mental health system is to engage knowledgeable elders in Canada’s First Nations, Inuit, and Métis communities to teach traditional ways and participate in the planning and delivery of mental health services.
According to the University of Alberta and Alberta Health and Wellness (2004), a culturally safe and competent mental health system is likely to lead to more use of mental health services by Aboriginal people, greater mental health awareness and reduction of stigma, and an increase in awareness of Aboriginal health and cultural issues by mental health workers and service providers.
The National Aboriginal Health Organization’s concept of cultural safety can clearly be applied beyond Aboriginal and Indigenous populations. In fact, this definition of cultural safety is broad enough to be applied to all people, and application of this concept meshes with the concept of person centred care, a key principle underpinning
Achieving cultural safety in practice, policy and system development is a commitment and requires skill and awareness at all levels. The following suggestions for facilitating cultural safety within the mental health system have been offered:
` Employ mental health workers from ethnocultural backgrounds, and train service providers so that awareness of, and responsiveness to, diverse needs and strengths becomes commonplace (Sadavoy, Meier & Ong, 2004; MHCC, 2009).
` Accreditation bodies and provider organizations adopt standards enforcing culturally safe and competent practices (Sadavoy, et al., 2004;
MHCC, 2009).
` Actively and meaningfully involve seniors from diverse populations in policy development, implementation, evaluation, and review (Seniors Psychosocial Interest Group, 2004).
` Ensure that service providers have the training required to increase their capacity to become culturally competent in service to Canada’s First Nations, Inuit, and Métis elder populations (Province of Alberta, 2004).
It is important to note that achieving cultural safety is a process, often considered a moving target. There is no recipe for implementing culturally safe standards and processes given the individual nature of what is considered
‘culturally safe’ in mental health care to people with lived experience and their caregivers. As such, ongoing reflection, awareness, and education are vital to moving towards a transformed system with improved cultural safety for all older adults.
DIVERSITY
In Canada the seniors’ population is heterogeneous and made up of many different groups (e.g., First Nations, lesbian-gay-bisexual-transgendered [LGBT], employed), each of which has diverse needs, strengths, circumstances, and aspirations. Every province has
immigrants, refugees, ethno-cultural and racialized groups, and within these groups intersecting diversities, such as age, sexual orientation and gender, add an additional layer of complexities (MHCC Diversity Task Group, 2009). Variations in education, literacy, competency in official languages, health and income create additional vulnerabilities to marginalization. According to the Public Health Agency of Canada (2003),
Some persons or groups may face additional health risks due to a socio-economic environment, which is largely determined by dominant cultural values that contribute to the perpetuation of conditions such as marginalization, stigmatization, loss or devaluation of language and culture and lack of access to culturally appropriate health care and services.
https://www.canada.ca/en/public-health/services/health- promotion/population-health/what-determines-health/what-makes-canadians-healthy-unhealthy.html
Although it is estimated that 30 to 60% of persons with a moderate or severe developmental disability have a mental disorder, diagnosis and treatment are difficult given overlapping comorbid symptoms, communication barriers and a scarcity of expertise in both developmental disability and psychogeriatrics (Dual Diagnosis Task Force of the Public Policy Committee, 1998). The National Advisory Council on Aging (2004) report, Developmental Disability, Mental Health and Illness, identifies a number of factors
that contribute to the marginalization of seniors with developmental disabilities:
The notion and the reality of differences in capacity have often caused them to live parallel lives socially and economically. This means that mainstream
information on disease prevention may not be reaching them. This is compounded by the rarity of experts on aging with developmental disabilities and the difficulties of communication – possible factors in preventable or undiagnosed conditions, and lack of access to proper care and other services in the areas of physical or mental health. Social and financial supports are also critical to the continued well-being of seniors with disabilities (p. 6).
Investigation may be necessary to identify any inequities specific groups (e.g., developmentally challenged,
immigrant, homeless) may experience or special issues and challenges they face that increase their vulnerability and marginalization, with concomitant risk to their mental health. This is necessary to ensure that information, education, interventions, services, programs and policies are appropriately tailored to the characteristics and needs of specific groups.
LGBT caregivers experience challenges that shape the caregiving experience as well as service provision/
utilization. Specifically, LGBT individuals may experience barriers to accessing services because of their own encounters with discrimination or prejudice. Older LGBT adults may be perceived not to have ‘families’ or support for families, whereas the literature shows this not be the case. Thus, intervention options that include family members (e.g. family support therapies), or religiously based support interventions can be impacted by treatment provider beliefs/stereotypes about LGBT individuals and
what would be considered “appropriate” care. As Coon (2004) points out, there may be hesitation for LGBT caregivers to participate in support groups that would involve them self-disclosing their sexual orientation. Further, older LGBT may experience difficulties disclosing or “coming out” that younger individuals would not.
Attending to Canada’s many diversities is an ongoing challenge for mental health providers. The Out of the Shadows report (Standing Senate Committee on Social Affairs, Science and Technology, 2006), noting the diversity of the senior population, asserts that the Canadian mental health system has failed to recognize the ‘uniqueness and diversity of seniors’ needs, resulting in barriers accessing services.
• Barriers related to diversity that may be faced by seniors accessing the mental health system include: limited understanding and capacity to negotiate the current system
• Lack of services that combine ethnocultural, geriatric, and psychiatric care
• Inadequate interpreter services or lack of materials and services in spoken language
• Reluctance to acknowledge mental health problems for fear of stigma (Sadavoy et. al, 2004; Canadian Mental Health Association, Ontario, 2010)
The Seniors Mental Health Policy Lens (MacCourt, 2008) provides a framework for identifying diversity and for considering the needs of diverse seniors populations and can be applied to programs and policies that affect older adults.
In order to reach seniors from diverse cultures, materials and services must be developed and delivered in a culturally sensitive manner (Sadavoy, et al., 2004).
A highly promising intervention for Chinese female caregivers demonstrates that interventions can be successfully tailored to accommodate ethnocultural beliefs about dementia. Specifically, Gallagher-Thompson and Coon (2007) provided an in-home behavioural management (IBHM) psychoeducational support program, based on CBT theoretical underpinnings. This intervention was able to show significant effects on caregiver depressive symptoms and caregiver related stress. The decision to modify components of the intervention, such as delivery of the behavioural management in-home versus an external setting, and to adapt the language and communication style (e.g. rephrasing “assertiveness training” to “practicing ways to communicate effectively with those who can assist with caregiving,”) as well as particular content issues
` Utilize the Seniors Mental Health Policy Lens to assess whether any seniors affected by a specific program or policy are likely to experience inequities or negative impacts resulting from their memberships in marginalized groups.
Value orientation in terms of beliefs about health and illnesses in general, and mental health in specific varies among cultures. Similarly expectations about familial caregiver roles and responsibilities as in filial piety can also vary in ways that impact on how seniors of diverse ethno-cultural groups and their families access help with behavioural and mental health challenges. Availability of culture appropriate care and culture competent care providers in the mental health realm is critically important to addressing the mental health needs of seniors in a culturally safe way.
Given the many dimension of diversity, examples exhaustively demonstrating its importance is beyond the scope of these Guidelines.
CAREGIVERS AS VITAL PARTNERS IN CARE
Support for family caregivers is a vital element of a comprehensive integrated mental health system for seniors. Caregivers provide more than 80% of care to seniors, and contribute more than $5 billion of unpaid labour to the health care system (Hollander, Liu, & Chappell, 2009). As the number of seniors grows (to 27% by 2050), so will the need for families to provide care to them (Butler-Jones, 2010). Many caregivers value providing care and experience positive benefits from doing so. Problems arise when the emotional, physical and time demands of caregiving become overwhelming, sometimes resulting in caregiver burn out and facility placement for the care receiver.
In spite of their important role caregivers are not adequately supported by health and social services or by public policy. Most public policies that affect caregivers directly or indirectly (e.g., health services, labour) have been developed without taking into account their needs and may have unintentional negative effects on caregivers and their
families, compromising their capacity to provide care.
The availability of appropriate services for the persons being cared for, and how they are delivered, affects the ability of caregivers to provide care and their well being.
Caregivers of (1) older adults generally (McGee, Tuokko, MacCourt & Donnelly, 2004), (2) of seniors with dementia (Dementia Service Framework Working Group, 2007), and (3) of caregivers/families of seniors with longstanding mental illness other than dementia (MacCourt & Tuokko, 2005), described the challenges they experience in obtaining support as follows:
` Ensure that caregivers are recognized through policy and programs and that they are valued as partners in care.
` Actively involve caregivers and family members of seniors with mental health problems and illnesses in the development of policies and services.
• There is a lack of appropriate information about, for example the mental illness of the person being cared for, what to expect and how to manage symptoms.
• Although the persons being cared for usually have several illnesses and physical limitations, care and services are fragmented and disconnected.
• The person they are caring for is “assessed to death” as a result of poor communication amongst providers.
• Information about resources is difficult to find as is how to access resources discovered (e.g., complexity of forms, language, print size and unclear eligibility criteria).
• Appropriate services (e.g., transportation, home support, respite, residential care) are seldom available when needed.
• Some services are not affordable for seniors and families with low income.
• Home support services are generally unavailable outside of business hours.
• Services in the community and long-term care beds are often not available when required due to lengthy wait lists even though eligibility criteria have been met.
This can precipitate crises and a breakdown in caregiving situations.
• There is little support to help families and caregivers cope with adjusting to, and coping with, the role of caregiving, especially when the person cared for has a severe or chronic mental illness.
• Some seniors’ services are not accessible to the persons being cared for if they, for example, smoke, use alcohol or have challenging behaviours.
• The “next available bed” policies in some provinces, (whereby seniors, particularly those waiting placement in hospital, must take the first available residential care bed regardless of cultural or location preferences), creates enormous distress, especially for spouses who are unable to drive or otherwise access transportation to visit.
• It is stressful (e.g., having to direct them, feeling invaded), to have many different people coming into the home to help—continuity of care providers is less distressing.
Caregiving is associated with physical and psychosocial symptoms, (including depression, stress, burden, fatigue, feelings of anger, guilt, grief and loss, frustration, loneliness, isolation, and decreased well-being and life satisfaction) which may place the physical and mental health of the caregiver, and their ability to continue to provide care, at risk (Keating, Fast, Frederick, Cranswick & Perrier, 1999). Those who provide care to chronically ill and elderly persons are vulnerable to elevated levels
` Ensure that the way in which services are organized and delivered is flexible, individualized as much as possible, responsive to the concerns and needs of caregivers, and available at the time needed.
` Ensure that there are mechanisms in place to facilitate effective communication between services and service providers involved in the care of individuals.
` Provide continuity of service providers to reduce number of people in the home and to maximize relationship building.
` Provide adequate, timely and flexible information, education, and practical and emotional support to caregivers.
` Ensure there is integration and coordination of information and services across systems for seniors with mental health problems and illnesses.
` Ensure that cultural and location preferences of seniors and their caregivers are respected when placement outside of the home is required.
a health crisis after 18 months of caregiving (Senior Education Centre, University of Regina, 1995). Caregivers also face “increased financial expenses such as fees for home care services, transportation costs for medical appointments, drug dispensing, technical aids and equipment, and home modification” (Maytree Policy in Focus, 2010, p. 2) that can cause strain.
Practical support, such as home support services to assist with physical needs of the care receiver and equipment and supplies such as continence pads and mobility aids, can assist caregivers. Respite care, in the home or outside of it, and day programs for the care receiver can reduce some of the burden of care and allow the caregiver to
“recharge.” Ensuring that services and programs are affordable and readily accessible when needed can also alleviate stress. General education and education and skill development related to specific challenges presented by the care receiver are required to facilitate coping with and managing care effectively. Psychoeducational support groups can alleviate stress associated with caregiving. Sorensen, Pinquart and Duberstein (2002) carried out a meta-analysis to synthesize the effects of 78 controlled caregiver intervention studies for 6 outcome variables, and found psycho-educational interventions for family caregivers of older adults resulted in significant improvements in caregiver burden, depression, subjective well-being and perceived caregiver satisfaction.
Caregivers’ needs are not formally acknowledged, assessed or addressed by health and social services in most Canadian jurisdictions and service providers lack evidence-informed tools and resources to do so. Findings from the Sustainable Caregiving Community Project in British Columbia (Antifeau, 2009) have confirmed the importance and significant benefit of assessing and addressing caregiver needs as early as possible and throughout the journey of dementia, in order to sustain an individual with dementia at home for as long as possible.
The Special Senate Committee on Aging (Carstairs & Keon, 2009), recommended a National Caregiver Strategy that would result in the creation of a framework by which all jurisdictions and sectors can meet the needs of an aging population and reflect the compassion that is fundamental to Canadian values (Carstairs & Keon, 2009). The Mental Health Commission of Canada (2009) reinforced this need in their call for support of family caregivers in its strategy framework.
` Support the mental and physical health and well-being of caregivers, especially older caregivers, early on in the disease process.
` Ensure caregivers are provided with the education, practical and emotional support necessary to carry out their role without jeopardizing their own health and mental well-being. Provide financial support for caregivers through mechanisms such as national and provincial taxation systems.
` Ensure all informal or family caregivers have access to psycho-educational and skill-building programs geared to the specific challenges of those for whom they are providing care.
` Create opportunities for peer support for older adults with mental health problems or illnesses and their families to meet with others who have experienced living with mental illness and knowledge about mental health services and supports in Canada.
SUPPORT FOR SERVICE PROVIDERS
In order to ensure a seamless system of mental health services is available to older adults, support for service providers should be considered a component of an integrated mental health system for older adults.
Most care of older adults, including those with mental health problems or illnesses, takes place in the community in people’s homes, retirement homes, and in independent and assisted living and long term care home settings. Service providers, usually home care workers or nursing aids, often care for seniors with very complex interconnected physical, cognitive and mental health care needs. It is important that these front line workers are able to identify and respond to seniors’ mental health and cognitive needs as well as to their physical health needs. Professional service providers including family physicians also provide frontline care and require similar (but more advanced) knowledge and skills appropriate to their responsibilities.
Core competencies/knowledge in the care of older adults required by service
providers, have been developed by the National Initiative for the Care of the Elderly (NICE), in collaboration with the Geriatric Education and Recruitment Initiative, in the following areas:
• Medicine as developed by the Canadian Geriatrics Society
• Psychiatry as developed by the Canadian Academy of Geriatric Psychiatry
• Interprofessional as developed by the National Initiative for the Care of the Elderly In addition to the competencies needed to care for older adults, front line care providers (including family physicians) caring for seniors with mental health problems and
illnesses, including substance abuse, require additional knowledge and skills appropriate to their roles:
• Normal aging
• Risk and protective factors for positive mental health
• Geriatric conditions, co-morbidity, pharmacology
• Mental health problems and illness including dementia, substance misuse and addictions
• Behaviour management
` Ensure service providers (current and future) who work with older adults have access to education about the unique needs of seniors with or at risk of mental illness, and access to clinical and ethical consultations.
` Ensure service providers have support in carrying out their roles, including adequate supervision and mentoring, a healthy work environment and sufficient resources.
` Ensure that health care providers and community organizations have the knowledge, skills and time to offer older adults and their families accurate and timely information and education that are specific to the needs of seniors.
• Cultural competency
• Recovery orientation
• Skills in team work and collaboration
Specialized mental health clinicians and services can provide this knowledge through education, mentoring, and consultation about challenging situations. Formal mechanisms built through partnerships amongst the different components of a comprehensive system will ensure that this support is readily accessible in a timely manner.
Mechanisms such as video conferencing to rural areas and shared care with family physicians can facilitate broad delivery. Clinical practice guidelines and best practices are also available to inform evidence-based practice (see further information in section III Application of Knowledge and Evidence).
Mechanisms such as video conferencing to rural areas and shared care with family physicians can facilitate broad delivery. Clinical practice guidelines and best practices are also available to inform evidence-based practice (see further information in section III Application of Knowledge and Evidence).